Financial Agreement & Cancellation Policy

Group Therapy

Karen E. Engebretsen, Psy.D., LLC

Licensed Psychologist, PY 5409

1876 N. University Drive, Suite 200F, Plantation, FL  33322

 

     I hereby assume financial responsibility for all charges that may be incurred for group therapy as per this signed contract.

      I acknowledge that Payment is due IN FULL BEFORE the appointment. No credit will be given. Credit & Debit Cards accepted (except AmEx & Corporate Cards). I understand that time has been reserved exclusively for me and/or my family members and, therefore, agree to provide at least forty eight (48) hours advance notice** if unable to keep the scheduled appointment. Failure to cancel in a timely manner is a loss to Three people: 

  1. a) MYSELF, because I miss the scheduled appointment
  2. b) THE THERAPIST, who could have been treating someone during that time
  3. c) OTHER GROUP MEMBERS, who lose the benefit of you participation and wisdom

**FULL FEE for Late cancellations or missed appointments will be charged to credit card or bill sent by USPS.

 Unless otherwise agreed upon IN WRITING, I understand that I will be charged $60 per session. I will be expected to pay for FOUR SESSIONS in advance. If I do not cancel in accordance with above conditions, I will forfeit the fee for that session. No exceptions. There will be NO CHARGE for phone calls, emails or texts requesting to re-schedule appointments only.

      I understand that additional charges will be added to my account for professional services rendered by Dr. Karen (e.g., telephone contacts, consultations with other professionals, preparation of reports or specials forms, email communication, depositions, court time, etc.) depending on the nature of correspondence and time needed. A charge of $35 will be added to your account for checks returned due to insufficient funds.

     Insurance benefits: I understand that PAYMENT IN FULL is due when services are rendered regardless of insurance company benefits or their schedule of reimbursement. Billing statements may be prepared on behalf of the patient as a courtesy by the therapist but patients will be FULLY responsible for collecting all monies owed. Since this office is not on any insurance panels, utilization of insurance benefits is the sole responsibility of the patient.

      Non-insurance related billing will be assessed a $10.00 administrative fee per document. If monthly invoices are generated, payment for services rendered must be received in our offices by the invoice due date.  Failure to remit payment by the due date will be assessed a compounding interest of 28% APR (2.0875%/month). It is further understood that when the aged balance remains open beyond 60 days, it will be referred to an attorney for collection with court action providing final remedy. Any and all additional costs, legal fees, and interest incurred as a result of turning the account over for collection will be the patients’ responsibility and added to any outstanding balances. If these charges have not been properly satisfied, Dr. Karen has the right to pursue payment by all allowable means accorded by Florida State law and Federal law. Any default judgment administered by the Broward County System shall be considered a lien held by a secured creditor, the therapist. All disputes will be adjudicated in the Broward County Court System of Florida.

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Signature

Print Name__________________________________________________       Date _________________

Address:  _____________________________ City: __________________Zip: _____________